Clarification from the agency

Current permanent employees of the Veterans Health Administration including permanent Veterans Canteen Service employees, current permanent full-time Hybrid Title 38 and permanent full-time Title 38 employees.

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The Medical Records Technician (CDIS-Outpatient and Inpatient) is responsible for reviewing the overall quality and completeness of clinical documentation. Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house while outpatient CDI focuses on improving clinical staff documentation of outpatient encounters through retrospective, ideally prior to coding and billing, review of outpatient encounters and extensive provider education.

Duties include, but are not limited to:

• Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
• Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits.
• Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
• Ensures documentation supports codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
• Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
• Ensures provider documentation is complete and supports the diagnoses and procedures coded.
• Reports incorrect documentation or codes in the electronic patient health record.
• Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access.
• Competent in use of the health record applications as well as the encoder product suite.
• Compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities.
• Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay.
• Reviews the appropriateness of patient working Diagnosis Related Group (DRG) and length of stay information by reviewing all clinical documentation, lab results, diagnostic information and treatment to ensure documentation reflects severity of illness, acuity and resource consumption.
• Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues.
• Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.

• This position is a Bargaining Unit position.
• Current and former Federal employees must submit copies of their most recent SF-50, (Notice of Personnel Action). The SF-50 must identify the position title, series, grade, step, tenure and type of service (Competitive or Excepted). In some cases, more than one SF-50 may be required to show a higher grade previously held.
• This position is in the Excepted Service.
• Interchange Agreements with Other Merit System: Employees who occupy medical or medical-related positions and were appointed under 38 U.S.C. 4701(1) or (3) [formerly 38 U.S.C. 4104 (1) and (3)] must be serving in a full-time position without time limit and have served continuously for at least one year in this other merit system to be eligible to convert to the Title 5 System. Some exceptions to this rule may apply if you have previously acquired tenure under a Title 5 appointment.
• Veterans' preference does not apply for other current permanent Federal agency employees.

Conditions of employment

• You must be a U.S. Citizen to apply for this job.
• You may ne required to serve a probationary period.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• You may be required to serve a probationary period.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.
• Maybe subject to satisfactory completion of our credentialing process.

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

BASIC REQUIREMENTS:

a. United States Citizenship: Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

b. English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f).

c. Experience and Education:

(1) Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records.

OR,

(2) Education. An associate degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records).

OR,

(3) Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed.

OR,

(4) Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.
The following educational/training substitutions are appropriate for combining education and creditable experience:

(a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses.
(b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).

d. Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:

(1) Apprentice/Associate Level Certification through AHIMA or AAPC.
(2) Mastery Level Certification through AHIMA or AAPC.
(3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.

NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.

Grandfathering Provision: May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

GRADE DETERMINATION:

Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient), GS-9

(a) Experience. One year of creditable experience equivalent to the journey grade level (GS-08) of a MRT (Coder-Outpatient and Inpatient); OR, An associate's degree or higher, and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR, Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.

(b) Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.

(d) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all the following KSAs:

(1) Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
(2) Knowledge of anatomy and physiology, pathophysiology, and pharmacology to interpret and analyze all information in a patient's health record, including laboratory and other test results to identify opportunities for more precise and/or complete documentation in the health record.
(3) Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
(4) Ability to establish and maintain strong verbal and written communication with providers. v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
(5) Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICDCM and PCS, CPT, and HCPCS. They must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators.
(6) Knowledge of severity of illness, risk of mortality, complexity of care for inpatients, and CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided for outpatients.
(7) Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues.

Preferred Experience: Certified Coding Specialist (CCS); Certified Coding Specialist - Professional (CCS-P), Certified Coding Associate (CCA), Certified Professional Coder (CPC), Registered Health Information Technician (RHIT

References: VA Handbook 5005/122, Part II, Appendix G57http://vaww.va.gov/OHRM/Directives-Handbooks/Documents/5005.pdf.

The full performance level of this vacancy is GS-08. The actual grade at which an applicant may be selected for this vacancy is GS-09.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

How you will be evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

Rsum Reminder: Your rsum must include the following information each job listed:
1. Job title
2. Duties (be as detailed as possible)
3. Month & year start/end dates (e.g. June 2007 to April 2008)
4. Full-time or part-time status (include hours worked per week).

Please be aware that your answers will be verified against information provided on your rsum. Be sure that your rsum clearly supports your responses to all the questions by addressing your work experience in detail.